Clinical implications of endotoxin activity and Polymyxin-B hemoperfusion in critically ill patients with septic cardiomyopathy: A single-center, retrospective, observational study

BACKGROUND

To explore the association between endotoxin activity (EA) and septic cardiomyopathy (SCM), the relationship between endotoxin removal by Polymyxin-B hemoperfusion (PMX-HP) and recovery from SCM (R-SCM), and the correlation between R-SCM and the 28-day mortality in septic patients admitted to the intensive care unit (ICU).

METHODS

Observational study that included patients admitted to two ICUs of a tertiary university hospital between April 2011 and December 2019, who received PMX-HP for sepsis/septic shock. The SCM and R-SCM were assessed by transthoracic echocardiography.

RESULTS

Among 148 patients, SCM was diagnosed in 60 (46%) of them and had no relationship with median EA (SCM group: 0.73; no-SCM group: 0.66, p = 0.48). Recovery from SCM was observed in 24 patients (49%) and was independently associated with the PMX-HP (OR 4.19, 95%CI [1.22, 14.3]; p = 0.02) and the SAPS2 II score (OR 0.94, 95%CI [0.9, 0.98]; p = 0.006). In the SCM group, the 28-day mortality was 60% and was independently predicted by R-SCM (OR 0.02, 95%CI [0.001, 0.3] p = 0.005) and SAPS II score (OR 1.11, 95%CI [1.01, 1.23] p = 0.037).

CONCLUSIONS

In septic patients, EA was not associated with SCM. However, endotoxin removal by Polymyxin-B hemoperfusion was associated with recovery from cardiomyopathy, which was a predictor of lower 28-day mortality.

Tumour stage and resection margin status are independent survival factors following partial pancreatoduodenectomy for duodenal adenocarcinoma

INTRODUCTION

There is limited published evidence on duodenal carcinoma due to its rarity. This study aimed to evaluate gastric outlet obstruction and obstructive jaundice along with pathological variables as survival factors in patients with duodenal adenocarcinoma following resection.

METHODS

Survival factor analysis was undertaken in patients undergoing duodenal cancer surgery from 1997 to 2015 in a single centre.

RESULTS

There were 57 patients of whom 18 had gastric outlet obstruction and 14 had obstructive jaundice. Fifty-three had a partial pancreatoduodenectomy and four had palliative bypass. Perioperative mortality and morbidity were 4% (2/53) and 47% (25/53) respectively in resected patients. With a median (95% confidence interval, CI) follow-up of 72 (57-86) months, median overall and recurrence-free survival was 38 months (95% CI 28-113) and 27 months (95% CI 18-83) respectively. The 1 and 3-year overall survival rates were 84% (95% CI 74-95) and 52% (95% CI 39-69) respectively. Median overall survival was 19 months in patients with gastric outlet obstruction vs 53 months in those without (p = 0.026) and 28 months in patients with obstructive jaundice vs 38 months in those without (p = 0.611). Univariate analysis revealed that tumour stage, resection margin status, pre-operative albumin status, gastric outlet obstruction and age were associated with poorer overall and recurrence-free survival but multivariate analysis confirmed only tumour stage and resection margin status to be significant.

CONCLUSION

Whereas gastric outlet obstruction in duodenal cancer appeared to be an important survival factor following partial pancreatoduodenectomy, multivariate analysis showed that only tumour stage and resection margin status were the key independent survival factors. Further multicentre studies are required to elucidate further characteristics of duodenal carcinoma and develop neoadjuvant/adjuvant management strategies.

Abstract P6-18-32: Profiling the early haematological dynamics and treatment modifications with palbociclib when used as first line treatment for ER-positive, HER2-negative metastatic breast cancer

Background: Palbociclib plus endocrine therapy (ET) significantly increases progression free survival compared to ET alone. Within PALOMA2 neutropenia was the most common AE and reason for dose reductions. No real data exists regarding dose reductions (DRs), dose interruptions (DIs), toxicities and benefits of palbociclib. Objective: To describe the early haematological dynamics, DRs/DIs with 1st line palbociclib in the context of a routine UK clinical practice. Methods: A prospective record was maintained of all patients with ER-positive, HER2-negative metastatic BC registered on the Pfizer patient programme at the Clatterbridge Cancer Centre NHS Foundation Trust. The clinical records of all patients commenced on treatment between April and December 2017 were reviewed, and clinico-pathological information, haematological data & toxicity data recorded. Data lock was 31st March 2018. Results: 48 patients received at least one cycle of treatment. The median age was 58, 29% (14/48) premenopausal & 71% (34/48) postmenopausal. 43% (21/48) had bone only disease with 42% (20/48) having visceral disease. The median number of cycles delivered 8 (range 2-11). DRs: 18/48 (38%) patients had a total of 21 DRs; 14/18 (78%) had 1 DR to 100mg; 1/18 (5%) 1 DR to 75mg; & 3/18 (17%) 2 DRs to 75mg. Reasons for DRs: 13 neutropenia, 2 leukopenia, 1 thrombocytopenia, 2 fatigue, 1 poor appetite, 1 sore mouth & 1 non-specially unwell. DIs: occurred in 24/48 patients (50%). Details of DRs/DIs by cycle will be presented. 85% (41 of 48) patients remain on treatment with 59% (24/41) on 125mg; 34% (14/41) on 100mg & 7% (3/41) on 75mg. FBC were available for 41/48 (85%) cases & dynamics considered over the first 6 cycles using FBC at the time of planned treatment delivery. Hb Baseline all patients (AP):129 (121 – 138), patients; patients with no dose reductions (NDR) 127 (123 – 139) & patient dose reduction (DR): 130 (118 – 136). Hb changes to cycles 2, 4 and 6 AP: 122 (115 – 131), 121 (116 – 127) and 125 (116 – 134); NDR:122 (110 - 135), 125 (117 - 127) and 131 (116 – 135); DR: 115 (112 - 120), 120 (115 - 124) and 122 (115 – 129). WCC Baseline AP: 6.8 (5.6 – 7.7); NDR: 7.2 (6.3 – 7.7); DR: 6.7 (5.2 – 7.7). WCC changes to cycles 2, 4 and 6 AP: 3.7 (2.9 – 4.4), 3.7 (3.1 – 4.4) and 3.3 (3 – 3.9); NDR: 3.5 (2.9 – 4.1), 3.6 (3.2 – 4.3) and 3.6 (3.1 – 4.1); DR: 2.1 (1.7 – 2.5), 4.3 (3 – 4.6) and 3.3 (2.8 – 3.5). ANC Baseline AP: 4.0 (3.2 – 5.1); NDR: 4.4 (3.4 – 5.0); DR: 3.6 (2.9 – 5.2). ANC changes to cycles 2, 4 and 6 AP: 1.5 (1.2 – 2.1), 1.7 (1.3 – 2.0) and 1.4 (1.2 – 1.9) NDR: 1.5 (1.1 – 2.1), 1.7 (1.4 – 2.0) and 1.3 (1.2 – 2.0); DR: 0.8 (0.6 – 0.8), 1.7 (1.2 – 2.3) and 1.4 (1.3 – 1.6). Plts Baseline AP: 298 (226 – 339), NDR: 252 (211 – 336); DR: 299 (253 – 339). Plt changes to cycles 2, 4 and 6 AP: 252 (198 – 310), 221 (186 – 259) and 200 (169 – 243). NDR: 249 (185 – 334), 229 (171 – 267) and 205 (177 – 263);DR: 208 (199 – 210), 216 (199 – 243) and 194 (162 -210). Conclusion: These initial real world data are consistent with the PALOMA2 data. Baseline WCC & ANC show no significant difference between NDR and DR cases. Updated data will be presented as well as outcome data for first time.

Citation Format: Bhojwani A, Flint H, Hall B, Wong H, Innes H, Cliff J, Ahmed E, Malik Z, O'Hagan J, Tolan S, Hall A, Hyatt K, Errington D, Alam F, Robson P, Thorp N, O'Reilly S, Law A, Cicconi S, Jackson R, Palmieri C. Profiling the early haematological dynamics and treatment modifications with palbociclib when used as first line treatment for ER-positive, HER2-negative metastatic breast cancer [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P6-18-32.

Abstract P6-17-27: Real world experience of the medical and surgical management of HER2 positive early breast cancer treated with neoadjuvant trastuzumab and pertuzumab via the NHS England cancer drug fund

Background: Studies of neoadjuvant (NA) dual HER2 blockade with trastuzumab (T) and pertuzumab (P) in combination with chemotherapy (CT) for early breast cancer (BC) have reported pathological complete response (pCR) rates of 39 to 62%. These studies also report manageable toxicity with diarrhoea reported in up to 73% of cases. To date no real-world studies have explored the efficacy and toxicity of this treatment. The objective of this study was to describe the medical and surgical management of women treated with neoadjuvant T-P in combination with CT (NAT-P-CT). As well as to determine the efficacy toxicity of NAT-P-CT in the context of a routine UK NHS clinical practice.

Methods: Patients with HER2+ BC treated neoadjuvantly with T-P accessed via the NHS England Cancer Drug Fund (CDF) at the Clatterbridge Cancer Centre NHS Foundation Trust between October 2016 and January 2018 were retrospectively identified. Clinico-pathological information, treatment data, nurse led toxicity review and echocardiographic were reviewed. Data lock was 19th June 2018.

Results: 78 female patients were identified with a median age of 50 years (IQR: 44.4-60.2). At diagnosis: median tumour size 30mm (23.0-47.5mm), 62% (48/78) were LN positive & 56% (44/78) ER+. CT regimens: 81% (63/78) FEC-DHP of these 30% (19/63) switched to weekly paclitaxel (wP). or nab-paclitaxel; 5% (4/78); AC/EC-DHP; 9% (8/78) TCHP with 13% (1/8) switched to wP. At time of analysis, 88% (69/78) had undergone definitive surgery. Surgical details: Breast: 52% (36/69) mastectomy & 48% (33/69) WLE, Axillary management: 51% (35/69) axillary dissection (Ax Dx) & 49% (34/69) sentinel node biopsy (4 performed prior to NA treatment). 91% (32/35) of those undergoing Ax Dx were LN+ at presentation, of these 59% (19/32) had no evidence of axillary involvement at surgery. pCR rate (ypT0/is, N0) was 46% (32/69) [pCR by HR: ER+ 43% (21/49) & ER- 55% (11/20]. pCR for 20 patients switched to wP was 60% (12/20). 7% (5/69) achieved pCR in the breast alone (in these LN status ITCx1, micrometsx3 & macrometsx1). Of the 54% (37/69) with residual breast tumour median size was 13mm (1-22mm). Toxicity Data: Ejection fraction (EF) did not decline beyond 10% of baseline in any patients. Diarrhoea (any grade) occurred in 74% of cases, and CTCAE grade 3-4 toxicity occurring in >2% of patients: diarrhoea, fatigue, and infection. Updated analysis regarding pCR rate and toxicity, as well as initial outcome data will be presented.

Conclusion: These results (1) confirm the efficacy of NA T-P in a real world population; (2) support the use of NA wP; (3) indicate significant proportion of patients axilla are downstaged & (4) reveal diarrhoea rates in keeping with the literature. Currently, NHS England rules do not allow wP to be used routinely in NA setting with T-P this should be reviewed in light of these data and those of the BERENICE study. Measures to identify patients who can avoid axillary dissection as well as to mitigate diarrhoea should be considered.

Citation Format: Hall B, Bhojwani A, Innes H, Ahmed E, Cliff J, Malik Z, O'Hagan J, Tolan S, Hall A, Hayat K, Errington D, Alam F, Thorp N, Flint H, Law A, Wong H, O'Reilly S, Jackson R, Cicconi S, Palmieri C. Real world experience of the medical and surgical management of HER2 positive early breast cancer treated with neoadjuvant trastuzumab and pertuzumab via the NHS England cancer drug fund [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P6-17-27.

The Application of Two Different Blood Cell Separators to Harvest CD34+ Cells in Patients Suffering from Non Hodgkin's Lymphoma

From January 1996 until now, thirty-eight PBSC procedures were carried out on 20 patients suffering from NHL, mobilized by polichemotherapy regimens plus recombinant human Granulocyte-Growth Factor (rhG-CSF). Patients were enrolled in PBSC procedures using Dideco Excel (group A) and Cobe Spectra v.4.7 (group B) blood cell separators. Twelve patients were enrolled in group A (6 males and 6 females, median age 33) and 9 patients in group B (5 males and 4 females, median age 55). The mean White Blood Cell (WBC) and Mononuclear Cells Fraction (MNC) peripheral blood counts were not statistically different in either group and neither were blood CD34+ cell peripheral counts. CD34+ cell peripheral value was predictive of the CD34+ yield while mean values of harvested CD34+ cells were not significantly different. CD34+ cell efficiences were statistically the same. The CD34+ cell purity of the apheresis harvest was statistically different between the two groups (group A = 3.0 ± 2.2%; group B = 1 ± 0.9%) p = 0.001. High CD34+ cell yields were observed in both groups which confirms that both blood cell separators are able to harvest hematopoietic progenitor cells from peripheral blood.

Percutaneous pedicle screw fixation in polytrauma patients

PURPOSE

The clinical outcome of polytrauma patients underwent spine fixation was analyzed and correlated both to surgical time (early versus delayed) and to fixation type (open versus percutaneous).

METHODS

Twenty-four polytrauma patients were retrospectively evaluated. Patients were evaluated according to age, accident dynamic, mechanical ventilation need, blood transfusion need, SAPS II score, type of vertebral injury, time of fixation (within or after 72 h) and type of fixation.

RESULTS

Nine patients underwent percutaneous pedicle screw fixation and 12 open fusion. An early fixation allows better clinical outcome considering ICU stay (13.7 versus 21.71 days), H-LOS (25.8 versus 69.5 days), mechanical ventilation need (7 versus 16.2), blood transfusion need (250 versus 592 cc).

CONCLUSIONS

In polytrauma patients an early spine fixation improves clinical outcome. Patients underwent percutaneous screw fixation showed a better outcome compared to open surgery group obtained despite worst clinical conditions.

Non-tunneled central venous catheters in adult stem cell transplantation recipients: An effective option

Stem cell transplantation (SCT) recipients require central venous catheter (CVC) insertion for the administration of chemotherapy, antibiotics and total parenteral nutrition. Traditionally, tunneled CVC have been considered as the golden standard although they require surgery for both insertion and removal. We prospectively evaluated the use of a non-tunneled CVC in 182 consecutive patients who had undergone allogenic or autologous SCT. The median duration of CVC was 4 weeks (range 1-24) with a significant difference between allogenic (8 weeks, range 2-24) and autologous SCT (4 weeks, range 1-24) (p<0.0001). The life expectancy of the CVC was significantly influenced by spontaneous removal, which occurred in 26 patients (13.8%). There was a significant increase of this complication in allogenic SCT (p=0.039). The overall incidence of sepsis was 24.5%, although catheter-related sepsis was microbiologically documented by positive culture of the tip only in 17 cases (9%). Non-tunneled CVC in adult SCT recipients allowed (a) bedside insertion and removal, (b) guidewire replacement for diagnostic or therapeutic purposes (dialysis or pheresis procedures) thus reducing the need for repeated venipunctures. (The Journal of Vascular Access 2001; 2: 168-174).

NGF-withdrawal induces apoptosis in pancreatic beta cells in vitro

AIMS/HYPOTHESIS

Using primary cultures of human pancreatic islets, purified human pancreatic beta cells and the mouse beta TC6-F7 cell line, we analysed the expression of nerve growth factor, (NGF/NGF) receptors in beta cells. To investigate whether NGF could sub-serve an autocrine antiapoptotic role in beta cells, we studied the effects of NGF withdrawal using a neutralizing monoclonal anti-NGF antibody.

METHODS

The expression of NGF and NGF receptors (gp140(Trk-A) and p75(NTR)) were analysed by RT-PCR and immunofluorescence. Pulse-chase experiments and beta cell/PC12 co-cultures were used to investigate NGF production and secretion from beta cells. Possible apoptosis induced by NGF withdrawal was monitored by phosphatidylserine translocation, nucleosomal formation, DNA laddering and FACS analysis. Involvement of transcription/translation mechanisms were investigated as well as the gp140(Trk-A) required. Finally, signal transduction pathways typically involved in apoptotic mechanisms were analysed by western blot analysis.

RESULTS

We show that NGF and both NGF receptors, gp140(Trk-A) and p75(NTR) are expressed in beta cells where NGF is produced and secreted in a biologically active form. NGF-withdrawal induces beta-cell transcription/translation independent apoptosis but mediated by gp140(Trk-A). Analysis of signal transduction pathways revealed that NGF withdrawal inhibits the PI3-K, protein kinase B (AKT), Bad survival pathway and activates c-Jun kinase (JNK) whereas ERKs and p38 mitogen-activated protein kinase (MAPK) are not affected. Moreover, Bcl-XL, but not Bcl-2 protein expression are reduced.

CONCLUSION/INTERPRETATION

We suggest that the integrity of the NGF/NGF receptor system and NGF bioavailability participate in controlling beta-cell survival in culture which represents a key issue for improving possibilities for transplantations in the treatment of diabetes.

Immune reconstitution after autologous selected peripheral blood progenitor cell transplantation: comparison of two CD34+ cell-selection systems

BACKGROUND

Selection of CD34+ PBPCs has been applied as a method of reducing graft contamination from neoplastic cells. This procedure seems to delay lymphocyte recovery, while myeloid engraftment is no different from that with unselected PBPC transplants.

STUDY DESIGN AND METHODS

Lymphocyte recovery was studied in two groups of patients who underwent autologous CD34+ PBPC transplant with two different technologies (Ceprate SC, Cellpro [n = 17]; CliniMACS, Miltenyi Biotech [n = 13]). The median number of CD34+ cells transfused was 3.88 x 10(6) per kg and 3.32 x 10(6) per kg, respectively. Residual CD3 cells x 10(6) per kg were 4.97 and 0.58, respectively (p = 0.041). Residual CD19 cells x 10(6) per kg were 1.33 and 0.73, respectively (NS).

RESULTS

No differences were found between the two groups in total lymphocyte recovery to >0.5 x 10(9) per L, which achieved a stable count by Day 30. During the study period, the CD4+ cell count remained below 0.2 x 10(9) per L, and the B-cell subset showed a trend toward normalization. CD3/HLA-DR+ and CD16/56 increased markedly in both groups by Day 30. An increase in CMV (13%) and adenovirus (17.4%) infection was found in both groups.

CONCLUSION

Both CD34+ cell selection technologies used here determined an excellent CD34+ cell purity and an optimal depletion of T cells. The high rate of viral complications is probably due to the inability of residual T cells left from the CD34+ cell selection to generate, immediately after transplant, an adequate number of virus-specific lymphocytes.

Neurotrophins and neurotrophin receptors mRNAs expression in pancreatic islets and insulinoma cell lines

CONTEXT

It is worth noting that islets and betaTC6-F7 cells share a common pattern of expression of neurotrophins and neurotrophin receptors. Recently, several studies have hypothesized a role for nerve growth factor in pancreatic development and maturation, suggesting that nerve growth factor may be a survival factor for pancreatic beta-cells.

OBJECTIVE

The aim of the present study was to investigate the pattern of expression of neurotrophins and their relative receptors both in rat pancreatic islets and in a wide panel of insulinoma cell lines.

MAIN OUTCOME MEASURES

A semi-quantitative reverse-transcription polymerase chain reaction analysis was performed on ribonucleic acids extracted from these cells.

RESULTS

Reverse transcription-polymerase chain reaction analysis demonstrates that brain-derived neurotrophic factor, as well as neurotrophins 3 and 4, are expressed both in islets and in all insulinoma cells, while nerve growth factor is expressed only in islets, betaTC6-F7 cells and, at a low level, in RIN 1046-38 cells. Receptors protein tyrosine kinase A and C are ubiquitously expressed both in islets and insulinoma cells. Tyrosine kinase B is absent in HIT-T15 cells.

CONCLUSIONS

These data indicate that betaTC6-F7 cells are a suitable model for studying the role of neurotrophins in the survival of beta-cells.

Intracellular localization and isoform expression of the voltage-dependent anion channel (VDAC) in normal and dystrophic skeletal muscle

Voltage-dependent anion channels (VDACs) are a family of pore-forming proteins encoded by different genes, with at least three protein products expressed in mammalian tissues. The major recognized functional role of VDACs is to permit the almost free permeability of the outer mitochondrial membrane (OMM). Although VDAC1 is the best known among VDAC isoforms, its exclusively mitochondrial location is still debated. Therefore, we have measured its co-localization with markers of cellular organelles or compartments in skeletal muscle fibers by single or double immunofluorescence and traditional as well as confocal microscopy. Our results show that VDAC1 immunoreactivity corresponds to mitochondria and sarcoplasmic reticulum, while sarcolemmal reactivity, previously reported, was not observed. Since VDAC1 has been suggested to be involved in the control of oxidative phosphorylation, we sought for possible gene regulation of VDAC1, VDAC2 and VDAC3 in skeletal muscle of the dystrophin-deficient mdx mouse, which suffers of an impaired control of energy metabolism. Our results show that, while VDAC1 mRNA and protein and VDAC2 mRNA are normally expressed. VDAC3 mRNA is markedly down-regulated in mdx mouse muscle at different ages (before, during and after the outburst of myofiber necrosis). This finding suggests a possible involvement of VDAC3 expression in the early pathogenic events of the mdx muscular dystrophy.

Molecular and functional characterization of pituitary adenylate cyclase-activating polypeptide (PACAP-38)/vasoactive intestinal polypeptide receptors in pancreatic beta-cells and effects of PACAP-38 on components of the insulin secretory system

It has been previously demonstrated that pituitary adenylate cyclase-activating polypeptide (PACAP) regulates insulin secretion. PACAP exerts its biological action by binding to at least three different receptor subtypes coupled to different signal transduction mechanisms. The signaling pathways underlying the insulinotropic effect of PACAP involve mainly the activation of adenylate cyclase to form cAMP, which directly and indirectly, through increased intracellular Ca2+, stimulates insulin exocytosis. In the present study we have characterized the functional and molecular expression of PACAP/vasoactive intestinal polypeptide receptors isoforms and subtypes and its isoforms in a beta-cell line and in isolated rat pancreatic islets. Although insulinoma cells express the messenger RNA encoding PAC1 (-R and -hop variants), VPAC1 and VPAC2, binding experiments indicate the preponderance of PAC1 over VPAC 1-2 receptors. We have also shown that the main signaling pathway of PACAP in beta-cells is mediated by adenylate cyclase, whereas the inositol 1,4,5-trisphosphate pathway is almost inactive. Furthermore, we have demonstrated that PACAP exerts long-term effects on beta-cells, such as transcriptional regulation of the insulin gene and genes of the glucose-sensing system (GLUT1 and hexokinase 1).

Inappropriate antidiuretic hormone secretion after high-dose thiotepa

High-dose thiotepa has been successfully included in a variety of conditioning regimens for stem cell transplantation in hematological and solid neoplasms. Toxicity of high-dose thiotepa mainly manifests as profound myeloablation and some degree of liver damage. We report a case of inappropriate secretion of antidiuretic hormone (SIADH) in a patient with primary CNS lymphoma who underwent therapy with high-dose thiotepa.

The application of two different blood cell separators to harvest CD34+ cells in patients suffering from non Hodgkin's lymphoma

From January 1996 until now, thirty-eight PBSC procedures were carried out on 20 patients suffering from NHL, mobilized by polichemotherapy regimens plus recombinant human Granulocyte-Growth Factor (rhG-CSF). Patients were enrolled in PBSC procedures using Dideco Excel (group A) and Cobe Spectra v.4.7 (group B) blood cell separators. Twelve patients were enrolled in group A (6 males and 6 females, median age 33) and 9 patients in group B (5 males and 4 females, median age 55). The mean White Blood Cell (WBC) and Mononuclear Cells Fraction (MNC) peripheral blood counts were not statistically different in either group and neither were blood CD34+ cell peripheral counts. CD34+ cell peripheral value was predictive of the CD34+ yield while mean values of harvested CD34+ cells were not significantly different. CD34+ cell efficiencies were statistically the same. The CD34+ cell purity of the apheresis harvest was statistically different between the two groups (group A = 3.0+/-2.2%; group B = 1+/-0.9%) p = 0.001. High CD34+ cell yields were observed in both groups which confirms that both blood cell separators are able to harvest hematopoietic progenitor cells from peripheral blood.